DRESS Syndrome Following Anti-Tubercular Therapy: A Case Report

BackgroundDrug rash with eosinophilia and systemic symptoms syndrome is a severe T-cell-mediated adverse drug reaction characterized by a skin rash, fever, hematologic abnormalities, and internal organ involvement following prolonged exposure to a causative medication. Drugs associated with drug rash with eosinophilia and systemic symptoms syndrome include anticonvulsants, allopurinol, antibiotics, and nonsteroidal anti-inflammatory drugs. Fluconazole is an exceedingly rare cause of drug rash with eosinophilia and systemic symptoms syndrome, with only one previously reported case in abstract form. We present a case of a woman with pulmonary coccidioidomycosis who developed fluconazole-induced drug rash with eosinophilia and systemic symptoms syndrome, presenting with an unusual clinical feature.Case presentationA 19-year-old Hispanic woman was taking fluconazole for pulmonary coccidioidomycosis. A total of 30 days after starting fluconazole, she developed a generalized skin rash. Despite this, she continued taking the medication. Then 1 week later, she experienced facial swelling and a sensation of “throat closing.” She also developed fever, axillary lymphadenopathy, eosinophilia, atypical lymphocytes, and hepatitis. Fluconazole was discontinued, and she was treated with intravenous methylprednisolone, which led to an overall improvement in her condition. During hospitalization, her antifungal therapy was switched to posaconazole. However, within 24 hours, she again experienced the “throat closing” sensation, which was relieved with an epinephrine injection. The patient was discharged on Day 6 with oral methylprednisolone. Again, 9 days after discharge, her symptoms recurred, including facial swelling and new skin rashes. She was readmitted and treated with famotidine, corticosteroids, and diphenhydramine. Her general condition and skin rashes gradually improved, with complete resolution of the rash 3 months after the initial eruption.ConclusionWe present a case of a woman with pulmonary coccidioidomycosis who developed drug rash with eosinophilia and systemic symptoms syndrome induced by fluconazole. Our case meets Bocquet’s diagnostic criteria and is categorized as “definite” drug rash with eosinophilia and systemic symptoms by the Registry of Severe Cutaneous Adverse Reactions. Drug rash with eosinophilia and systemic symptoms syndrome is a T-cell-mediated type IV hypersensitivity reaction; however, our patient also exhibited a unique symptom—a sensation of “throat closing”—suggestive of angioedema and a Type I hypersensitivity component. This symptom appeared while she continued fluconazole after the onset of drug rash with eosinophilia and systemic symptoms syndrome and recurred upon the initiation of posaconazole. Although both fluconazole and posaconazole belong to the triazole antifungal class, true allergic cross-reactivity medicated by IgE is rare probably due to their structural differences. This suggests cross-reactivity may occur even with structurally unrelated drugs in drug rash with eosinophilia and systemic symptoms syndrome. Clinicians managing suspected cases of drug rash with eosinophilia and systemic symptoms syndrome should promptly discontinue the offending drug and exercise caution when prescribing alternative medications to minimize the risk of further hypersensitivity reactions.

Intravenous Immunoglobulin May Be Beneficial as an Add-on Therapy in DRESS

Adverse Drug Reactions (ADRs) are unexpected reactions to a medicine administered in the correct manner and at the proper dosage. Drug Rash with Eosinophilia and Systemic Symptoms syndrome (DRESS syndrome) is a Severe Cutaneous Adverse Reaction (SCAR) type of ADR with complicated clinical features involving several organ systems of the body; frequently involved organs are the liver, kidney, lungs, and other organs. Prompt recognition and correct diagnosis, followed by withdrawal of the causative agent, can promote appropriate treatment, accelerate recovery, and reduce the related morbidity and mortality. We have, herein, presented a case of a 42-year-old female with a history of leflunomide intake for plantar fasciitis. The patient subsequently developed fever, gastrointestinal tract disturbance, facial edema, liver injury, skin rash, hematologic abnormalities (eosinophilia), hepatosplenomegaly, and lymph node enlargement. The probability of leflunomide-induced DRESS syndrome was rated as "definite", with with a score of eight graded by RegiSCAR. The suspected causative agent was withdrawn, and the patient was managed symptomatically. Following her management and discharge, she again encountered similar complaints after administration of the cefuroxime tablet. The causality assessment of the reactions was done using the WHOUMC scale and Naranjo's assessment scale, and a "probable" reaction was found for both drugs. The presented case contributes to the existing global literature regarding exceptional clinical presentations. Leflunomide and cefuroxime drugs have the potential to cause DRESS syndrome. Thus, they should be handled cautiously, and if such a reaction occurs, it should be reported to the responsible authorities.

Drug reaction with eosinophilia and systemic symptoms syndrome following vaccination with the AstraZeneca COVID-19 vaccine

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a severe drug-induced hypersensitivity reaction with varied presentations. We report a rare case of DRESS syndrome with toxic epidermal necrolysis (TEN) overlap associated with non-Hodgkin lymphoma (NHL). A 52-year-old male with retroviral disease presented with fever and diffuse skin peeling with mucosal erosions. The patient was on antitubercular therapy (ATT) for 1 month for suspected tubercular cervical lymphadenitis. He had facial edema, extensive skin tenderness, and denudation with a positive Nikolsky’s sign, icterus, hepatosplenomegaly and multiple enlarged immobile nontender cervical, and axillary and inguinal lymph nodes. Investigations showed leukocytosis with hepatic and renal dysfunction. Skin histopathology was consistent with TEN. Based on Registry of Severe Cutaneous Adverse Reaction criteria, a diagnosis of ATT-induced DRESS with TEN overlap was made. Cervical lymph node biopsy and immunohistochemistry confirmed diffuse large B-cell NHL. ATT was withheld and the patient was treated with systemic steroids and assessed for initiation of chemotherapy. The profound immunological dysregulation in individuals with retroviral disease leads to varied clinical presentations, increasing the chances of diagnostic errors, and culminating in challenging scenarios. Therefore, seemingly innocuous symptoms and signs warrant thorough evaluation. Sound clinical acumen and prompt investigations for unusual causes such as malignancies can improve outcomes by aiding accurate diagnosis as well as avert untoward complications such as DRESS syndrome/TE.

Comments on: DRESS syndrome

Minocycline induced drug rash with eosinophilia and systemic symptoms complicated by hemophagocytic lymphohistiocytosis

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is one of the severe cutaneous adverse reactions with a mortality of 10% and is characterized by hematological abnormalities and organ involvement. Many drugs have been implicated in DRESS, and most often, it is related to aromatic anticonvulsants. We hereby report a case of DRESS syndrome precipitated due to allopurinol, the diagnostic challenge it presented, and the successful treatment with corticosteroids.

Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome is a severe adverse drug reaction characterized by skin rash, fever, lymph node enlargement, and single or multiple organ involvement. Prompt diagnosis and withdrawal of the offending drug reduce mortality.We report a case of DRESS syndrome along with a review of the literature. We identified the case as DRESS syndrome based on the skin rash, fever, eosinophilia, and liver and kidney involvement. According to the European Registry of Severe Cutaneous Adverse Reactions to Drugs and Collection of Biological Samples (RegiSCAR), our patient had a score of 6.Drug rash with eosinophilia and systemic symptoms syndrome is a severe form of drug reaction with the potential for significant morbidity and mortality. Human leukocyte antigens (HLA) screening may be performed to prevent disease in susceptible patients. Steroids in a tapering dose are helpful in the resolution of symptoms.

Introduction: Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a rare, idiosyncratic subset of drug-induced hypersensitivity syndrome manifesting as skin eruption, fever, lymphadenopathy, hematologic abnormalities, and multi-organ involvement. It presents usually after a latent period of 2 to 6 weeks as a diffuse erythematous rash with systemic symptoms and facial edema. It is now recognized as one of the severe cutaneous adverse reactions (SCAR) associated with high mortality, chiefly because of derangement of renal or liver functions. The cutaneous morphologies can be myriad, encompassing maculopapular, exfoliative dermatitis-like, pustular, erythema multiforme-like, Stevens-Johnson syndrome-like, and toxic epidermal necrolysis-like presentations. Case Presentation: We hereby report two young males who developed pruritic exfoliating erythematous rash after taking cephalosporin with paradoxical worsening despite drug withdrawal. They were diagnosed with ‘atypical DRESS syndrome’ according to the Japanese study group severe cutaneous adverse reactions (J-SCAR) criteria and treated successfully with systemic steroids and emollients. The J-SCAR scoring and the concept of atypical DRESS are useful in situations, where either all clinical and laboratory criteria are not present simultaneously, or typical clinical presentations wherein human herpes virus-6 (HHV-6) reactivation cannot be documented. Conclusions: These two cases were used to illustrate the hitherto obscure concept of atypical DRESS syndrome that presented with compatible clinical features but did not satisfy all the requisite criteria. We also highlight cephalosporins (one of the most commonly prescribed standard group of drugs) as a plausible but infrequently reported cause of this severe adverse cutaneous drug reaction.

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome, while uncommon, presents a potentially hazardous condition. It is a drug-induced multi‑system immunological hypersensitivity reaction, characterized by the triad of fever, rash, and internal organ involvement. This is a case report of a 60-year-old Indian female who developed a repeat episode of DRESS syndrome following modified anti-tuberculosis therapy (ATT). She had a past history of DRESS syndrome caused by first-line antitubercular drugs. This case report aims to highlight the challenges in managing DRESS syndrome in the context of tuberculosis (TB) treatment, as well as to emphasize the importance of prompt withdrawal of the culprit drugs and immediate initiation of appropriate supportive care. This case report also highlights the high risk of recurrence of DRESS syndrome following the re-administration of the offending medication, especially antitubercular drugs.

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Introduction: Drug reaction with eosinophilia and systemic symptoms syndrome or DReSS is a rare and life-threatening severe hypersensitivity reaction characterized by multiorgan involvement, with the liver as the common visceral manifestation. Approximately 10% of patients showed no changes in their eosinophil count. Sulfasalazine and non-steroidal anti-inflammatory drugs are frequently associated with DReSS. The diagnosis of this syndrome remains challenging due to the variety of clinical presentations. Case Illustration: We reported a 48-year-old woman who presented with pruritic generalized morbilliform eruption accompanied by facial edema and fever. Five weeks prior, she was treated with sulfasalazine and diclofenac sodium for spondyloarthritis. Her laboratory results showed elevated liver, suggesting drug-induced liver injury. DReSS syndrome was diagnosed by applying the European RegiSCAR. A favorable outcome and recovery of liver function are significantly seen after withdrawal of the suspected drugs, supportive treatment, and administration of systemic corticosteroid. Discussion: Sulfasalazine was one of the drugs frequently reported to cause DReSS syndrome. Liver involvement ranges from reversible elevation of liver function tests to hepatic necrosis. Withdrawal of causative drugs and administration of methylprednisolone were recommended, particularly for DReSS with liver involvement. Conclusions: DReSS syndrome can manifest with typical skin lesions and multiorgan involvement despite the absence of eosinophilia. The leading cause of mortality related to acute liver injury ranges from mild transaminase to acute liver failure. Prompt cessation of the culprit drug, immunosuppressive therapy, and a multidisciplinary approach might prevent further complications and mortality.

Published on:June 2022 Journal of Young Pharmacists, 2022; 14(2):253-255 Case Report | doi:10.5530/jyp.2022.14.48 Authors: Meghna Gosi1, Sujit Kumar Sah1,*, Arya Merin1, Siddartha Ningappa Dhurappanavar1, Ashwini Padubidri Kombettu2 1Department of Pharmacy Practice, JSS College of Pharmacy, JSS Academy of Higher Education and Research, SS Nagar, Mysuru, Karnataka, INDIA. 2Department of Dermatology, JSS Hospital, JSS Academy of Higher Education and Research, SS Nagar, Mysuru, Karnataka, INDIA. Abstract: Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is an idiosyncratic and rare drug reaction that can be severe and life‑threatening if untreated. We present a 34 year old male patient, who developed DRESS syndrome after receiving phenytoin for 8 weeks and presented with rapidly progressive erythematous rash on trunk, face and upper extremities, fever and facial swelling. Abnormal laboratory findings, RegiSCAR score, and Naranjo’s probability scale revealed the association between phenytoin and DRESS syndrome. Phenytoin was withdrawn and adequately managed with systemic corticosteroids, antihistamine, and other symptomatic treatments. DRESS syndrome can be cured completely by early detection and removal of culprit drug along with other adequate symptomatic treatments.Key words: DRESS syndrome, Naranjo probability, Hypersensitivity reaction, Scale, Phenytoin, RegiSCAR score.

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a severe, delayed T-cell-mediated adverse drug reaction that affects visceral organs. Typical features include fever, rash, lymphadenopathy, haematological abnormalities and various visceral organ involvements, usually appearing 2-8 weeks after drug initiation. Although commonly affected organs include the liver, kidneys and lungs, pancreatic involvement is rare. We report a rare case of acute pancreatitis associated with DRESS syndrome due to carbamazepine. To the best of our knowledge, this is the first report identifying carbamazepine as a cause of DRESS-related acute pancreatitis.